What is the recommended treatment protocol for hypertension (Htn) using Lisinopril?

Lisinopril for Hypertension Treatment Protocol

Lisinopril, an ACE inhibitor, is recommended as a first-line treatment for hypertension, typically starting at 10mg once daily and titrating up to 20-80mg daily as needed to achieve target blood pressure of 120-129/80 mmHg. 1

Initial Assessment and Treatment Strategy

• ACE inhibitors like lisinopril are among the four major drug classes (ACE inhibitors, ARBs, dihydropyridine CCBs, and thiazide/thiazide-like diuretics) recommended as first-line treatments for hypertension 1
• For most patients with confirmed hypertension (BP ≥140/90 mmHg), combination therapy is recommended as initial treatment, but lisinopril monotherapy may be considered in low-risk patients, elderly patients (>80 years), or frail individuals 1
• The starting dose of lisinopril is typically 10mg once daily, with clinical studies showing significant BP reduction at this dose 2, 3

Dosing and Titration

• Lisinopril can be titrated up to a maximum of 20-80mg once daily based on blood pressure response 2, 4
• During the titration period, dose increases should be made at 2-4 week intervals until target BP is achieved 3
• In clinical studies, 40% of patients reached target diastolic BP (<90 mmHg) within the first week of treatment, and by the end of the titration period, 96-98% achieved BP goals 3
• For patients with impaired renal function (GFR ≤60 ml/min), a lower starting dose is recommended: 2.5mg for GFR <30 ml/min and 5mg for GFR 30-60 ml/min 5, 6

Target Blood Pressure

• The 2024 ESC guidelines recommend a target systolic BP of 120-129 mmHg for most adults with hypertension 1
• If this target cannot be achieved due to poor tolerance, the "as low as reasonably achievable" (ALARA) principle should be applied 1
• For patients with specific comorbidities (cardiovascular disease, chronic kidney disease, diabetes), a more stringent target of <130/80 mmHg is recommended 1

Combination Therapy

• If blood pressure is not adequately controlled with lisinopril monotherapy, a combination approach is recommended 1
• Preferred combinations include an ACE inhibitor (lisinopril) with either a dihydropyridine calcium channel blocker or a thiazide/thiazide-like diuretic 1
• Single-pill combinations are preferred when available to improve adherence 1
• If BP remains uncontrolled with a two-drug combination, progression to a three-drug combination is recommended (ACE inhibitor + dihydropyridine CCB + thiazide/thiazide-like diuretic) 1
• Combining two RAS blockers (e.g., ACE inhibitor and ARB) is not recommended 1

Special Populations

• Lisinopril is less effective in Black patients compared to Caucasians 2
• For Black patients, a combination of ARB with either a dihydropyridine CCB or thiazide-like diuretic may be more effective 1
• In elderly patients, dose should be adjusted based on frailty and comorbidities 1
• Lisinopril has shown efficacy in patients with renovascular hypertension but should be used with caution due to potential effects on renal function 2

Monitoring and Follow-up

• Blood pressure should be monitored regularly, with a goal of achieving target BP within 3 months 1
• Renal function and electrolytes should be monitored, particularly in patients with pre-existing renal impairment 1
• Lisinopril should be taken at the most convenient time of day for the patient to establish a habitual pattern and improve adherence 1
• Treatment should be maintained lifelong if well tolerated, even beyond 85 years of age 1

Common Side Effects and Precautions

• Most common side effects include dizziness and cough 4
• Less common side effects include rash and proteinuria 4
• Potential drug interactions exist with diuretics, potassium supplements, and possibly with nonsteroidal anti-inflammatory agents 4
• Angioedema is a rare but serious side effect that requires immediate discontinuation 6